0:01

I'm a pragmatist.

0:01

So I, I do like not to confuse the surgeon

0:06

or force them to make a phone call, but in teaching fellows

0:10

and visiting scholars, it, when I have a SLAP lesion, I,

0:14

I do use the numbers I have to admit, uh, shamefully,

0:17

um, one through 10.

0:19

And the reason I do that is, is one, it's fun.

0:22

Two, I like to educate them,

0:24

but I always tell them, if you are going

0:27

to use those Roman numerals, you better,

0:29

you better use the proper descriptor.

0:32

So the surgeon has an an idea in their head of exactly

0:35

what you're talking about.

0:37

So let's move on to this case.

0:39

Uh, this is a,

0:43

um, let's see.

0:45

We are on, this is a patient with a,

0:49

a diving injury while diving

0:51

for a ground ball is a young patient,

0:53

I believe 22 years of age.

0:56

And, um, there is a, a lesion here

1:00

and a bone, a bone abnormality, an area of edema.

1:04

Let's look at it in the sagittal projection.

1:06

Lemme blow them up a little bit for you.

1:11

And let's look at the coronal projection.

1:14

And it's in a location where

1:17

you would expect a hills sax lesion, uh, to be.

1:21

And where is that?

1:22

If you take the 12 o'clock position,

1:24

you should be no more than say, 20 degrees off that

1:28

for most hills sax lesions.

1:30

And the more medial they are, the more problematic they are

1:33

as you'll hear tomorrow.

1:35

So this is in a good spot. It's also not an erosion.

1:38

It doesn't have a sharp edge

1:40

to it like you would expect an impingement type

1:43

lesion to be.

1:44

So it has this ill-defined character to it, uh, consistent

1:48

with an impaction phenomenon.

1:50

So if you have a hill sax, the odds

1:51

of you not having a label tear are very low.

1:54

So why is this case if it is a dislocation?

1:59

Diving for a ground ball is a good mechanism

2:02

to dislocate the shoulder, falling on the ground

2:04

with the arm extended.

2:06

Um, and, and the reason is as follows.

2:09

Let's look at the coronal.

2:11

And remember, we said we don't like to see our

2:15

vertical longitudinal signals continue or propagate

2:19

or become more complex or more conspicuous

2:22

or change direction as we go posteriorly.

2:25

And we use a lot of these signs

2:27

because we don't do a lot of arthrography, um, uh,

2:30

for slap lesions in our practice.

2:32

And indeed, this patient has a, a slap two abnormality.

2:37

Now, did that slap two abnormality occur as a result

2:40

of the the diving, uh, event?

2:43

I, I don't know the answer to that, but there's more.

2:46

Here's the, here's the vertical longitudinal slap, two

2:51

abnormality in the axial,

2:52

and now, now let's go from superior to inferior.

2:56

Another rule of thumb in the axial projection,

2:59

if you've got a sulcus or you've got a recess

3:03

and you are going from superior to inferior,

3:05

by the time you get to the equator of the humeral head, that

3:09

defect should begin to close down

3:12

and it should go away when you're in the lower quadrant.

3:14

And that is not occurring here.

3:17

We have that signal that we saw and look at this defect,

3:20

and it's there again and again and again.

3:25

It continues all the way down.

3:26

I mean, this thing should be snuggled right up on the

3:29

anterior bony glenoid.

3:31

So we, we do have what we expected,

3:33

which is an anterior inferior labral tear.

3:37

Um, this is a tear that I would describe as perthes, like

3:41

I know Don doesn't like to read perthes lesions.

3:44

We were discussing this earlier

3:46

unless, uh, we have arthrography.

3:49

Uh, but when I have a labral tear

3:51

and I can, I can affirm that the periosteum is not ruptured.

3:56

I will use that term perthes like,

3:58

and, uh, these perthes like lesions are associated

4:01

with macro instability and are associated with dislocations.

4:05

So what do we call this? What do we name the baby?

4:08

And this baby would be named slap five, uh,

4:12

because it starts superiorly

4:13

and goes into the anterior inferior quadrant.

4:17

Now, based on the lack of swelling up high,

4:20

I suspect at the shape of a lesion,

4:22

I suspect this was preexisting and that this was new.

4:26

And they met a collision lesion much as Dr.

4:29

Resnick described earlier.

4:31

So slap five collision lesion two at the top

4:36

with propagation or involvement

4:39

of the anterior inferior quadrant.

4:41

They probably do meet in the middle.

4:43

They did meet in the middle. They were contiguous.

4:45

Um, slap five. Any comments on this one? Yeah, just

4:48

Quickly. Um,

4:49

it is those multi quadrant lesions

4:53

that include the slap lesion superiorly

4:56

that can be associated with macro instability more commonly

4:59

for those that involve the anterior than

5:01

the posterior aspect.

5:03

But that is the exception.

5:04

It's the isolated superior ones that, uh, don't often have

5:08

that, although they can get micro

5:10

instability as we will talk about.

5:12

And then the other point, which I'll talk about tomorrow,

5:15

is why I separate ALSA and per Perth a lesion

5:19

because I have, you know,

5:20

a difference in the way I approach it.

5:22

Sure. And we were discussing this earlier.

5:25

Um, you know, I I tend

5:27

to use ALSA when I see the labral ligament as complex.

5:31

Actually the labrum more media underneath the periosteum

5:34

as opposed to sitting out a little more laterally.

5:37

But I think this is a subject for discussion tomorrow.

5:41

Um, any other comments? No. Okay.

5:43

Um, let's move on to the next one.